SOAP

Subjective

• 38 yo F presents with a 3-day history of dysuria, urinary frequency, and suprapubic discomfort. Denies hematuria, fever, chills, flank pain, or vaginal discharge.
• Mild intermittent asthma; Laparoscopic appendectomy (12/05/2018).
• Salbutamol (Ventolin®) 100 mcg INH PRN, Vitamin D3 1,000 IU PO daily.
• Non-smoker, social EtOH (2 drinks/week), works as an elementary school teacher, sexually active with 1 male partner (uses barrier contraception).
• Penicillin (maculopapular rash).

Objective

• BP 116/74 mmHg, HR 72 bpm, Temp 36.8 °C, RR 14/min, SpO2 99 % on RA.
• Alert, NAD. Abdomen soft, mild suprapubic tenderness, no guarding or rebound. Negative bilateral CVA tenderness.
• Point-of-care urine dipstick (24/10/2023 at 10:15): Positive leukocyte esterase, positive nitrites, trace blood, negative glucose/ketones. Urine HCG negative.

Assessment

• Acute uncomplicated cystitis (UTI).
• Clinical presentation and urinalysis consistent with lower UTI; no evidence of pyelonephritis.

Plan

• Nitrofurantoin (MacroBID®) 100 mg PO BID for 5 days. Phenazopyridine 200 mg PO TID PRN for 2 days for dysuria. RTC PRN if symptoms persist after completion of antibiotics.
• Advised to increase oral fluid intake. Reviewed red flags (fever, rigors, flank pain, N/V) warranting urgent reassessment. Discussed post-coital voiding for prevention.
• None required at this time.